Provider Demographics
NPI:1063019305
Name:PORTALES, MIRIAM (RBT)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:PORTALES
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W 68TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4926
Mailing Address - Country:US
Mailing Address - Phone:786-325-4901
Mailing Address - Fax:
Practice Address - Street 1:515 W 68TH ST APT 4
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4926
Practice Address - Country:US
Practice Address - Phone:786-325-4901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-120226106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107745000Medicaid